Joint examination

Joint examinationJoint examination is the basic examination of any joint. It doesn’t matter what joint we’re looking at, the same process should follow, whether it’s a knee, an ankle, or on this occasion, a wrist. All joints will move in a set parameter, so they will all have their normal, natural movement. But before we actually look at that, we look at the way the patient is holding themselves. So look, firstly, at the patient and what they are holding and how they’re holding it. If you look at people who have injuries in sport and this sort of stuff, they will test every joint before they start to move. So if you see a footballer go down and hurt his knee, they start off by moving the toes, then their ankle, then the knee, until they find the point of pain. And we are going to do exactly the same in our assessment of a wrist.

We will start off by making sure that we don’t move it into a position where it’s uncomfortable. And if the patient doesn’t want to move it from where they are, leave it in that position. We are looking for normal straight bones. We are looking for deviations, strange shapes, strange positions, unnatural movement, unnatural positions. We are also looking for swelling, blood vessels bursting, muscles damage, tendons, ligaments will swell very, very quickly when we damage a joint. Fluid will start to fill a joint and swelling takes place. It also creates heat, so feel the joint. Is the joint a normal temperature, or is it hot? Are there any bruises? Bruising will come to the surface. Ecchymosis, which is a fancy name for bruising, will come through to the surface very quickly. And you can see that starting to appear.

Are there any fractures or open areas? Has a bone fractured and come to the surface to the skin and maybe gone back inside again, or is it still protruding? So what are we actually seeing visibly? What can we feel? What can we sense? What is the patient telling us? And then we do a movement assessment, so the fingers, get them to move the fingers first. Say, “Can you move your fingers for me?” If the fingers are moving okay, without any major pain, we can rule the fingers out. We then come back to the thumb. Move the thumb and the joint and test the thumb joints. Say, “Move your thumb for me”, no problem there. Then we can gently get them to move the wrist itself. All we’re doing is working from the fingertip back to the point where we find the pain starts to occur, because they may be holding their wrist, but it may be mid shaft, it may be elbow joint.

We go back until we find the point of the problem or where the pain is actually coming from. Nice and gentle, take it back, press against it gently until the pain comes on and go the opposite way until the pain comes on. We are not trying to hurt the patient, we are trying to assess the amount of movement the joint has got, and where the pain starts to come in. We have got tendons, we have got ligaments, as well as multiple bones. So what we’re looking for is how the tendons flex, how far they will flex, and the actual normal movement of the joint itself. And all we are trying to do basically is assess the point where the pain kicks in and assess whether there are any fractures, whether there’s anything we need to do immediately to sort this problem out.

Another thing that’s always useful is to test the cap refill. Squeeze the blood from the fingertip, allow it to refill. Have we got an occlusion of a blood vessel travelling down into the hand itself? Is the hand colour a normal colour or is it changing colour? Is it going blue where we’ve got an occlusion to a blood vessel feeding the hand, basically stopping the blood supply to the hand? Is the hand warm? Is there a decent cap refill, showing us that the blood supply is coming past the fracture site itself, and then we’re going to use the appropriate treatment to make sure we stabilize that fracture before we move the patient to a hospital. We are going to look at visible, what we can see, verbal, what the patient tells us, what we can feel, what we can hear.

Another thing that sometimes occurs is crepitus. If you actually hold the joint and move the wrist gently, if there is a fracture sometimes you will get bone-on-bone movement, and that you can feel through the surface of the skin, on big joints and big bones, neck of femurs in the leg, and this sort of stuff, you can sometimes even hear it. We don’t want to exacerbate the problem, we don’t want to make it worse, we just want to do it nice and gentle to evaluate what we’re dealing with. It then needs to be immobilised in an appropriate method, before we transfer to hospital, and remember, the pain relief is always important. If the patient is in pain, treat the pain, before we start doing major examinations. We don’t want to put the patient in any pain whilst we do the examination, where we can avoid it.

Finally, always remember, swelling. When hands and limbs swell, things like watches and rings, wedding rings, in particular, become tight and very, very difficult to remove. So they’re better taken off early and put somewhere safe rather than after the swelling takes place and have to be cut off. And a very, very simple technique for getting the ring off, this might help some of you, if you get an oxygen mask and the elastic from an oxygen mask, feed the elastic underneath the ring itself, this works really well for tight-fitting rings, if you feed the elastic underneath the ring, like so. Feed it back and actually hold the finger and turn and spin, just close your fingers for me apart from the wedding ring finger like that, that’s it, and if we now pull and turn at the same time, the ring comes straight off on to the elastic.